Healthcare Provider Details

I. General information

NPI: 1255009163
Provider Name (Legal Business Name): ELM PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2021
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 W MAIN ST
LAKE CITY SC
29560-4400
US

IV. Provider business mailing address

800 W MAIN ST
LAKE CITY SC
29560-4400
US

V. Phone/Fax

Practice location:
  • Phone: 843-977-7337
  • Fax: 843-956-5415
Mailing address:
  • Phone: 843-977-7337
  • Fax: 843-956-5415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. HEATHER BROWN
Title or Position: PRACTICE ADMINISTRATOR
Credential: RN
Phone: 843-977-7337